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Month: August 2015

This is going to be controversial, I know. I am careful to label personal opinion where it is expressed. Feel free to call me out on it if you have data to support your position. I don’t claim to be the ultimate authority on this subject, only an educated commentator. I expect a lot of reaction and don’t plan to respond to it much, so please don’t expect a flame war. If you have strong views, express them, but I’d ask that you respect opposing views and don’t engage other commenters directly here. Take it private or go elsewhere.

There has been a series of laws passed in several states setting requirements for facilities that perform outpatient abortions. The provisions that create the most controversy are those requiring providers who do procedures in these settings to have admitting privileges at a nearby hospital so that they can treat complications arising from the procedure.

Pro-abortion voices say that this constitutes an undue burden on the facility and will force many of them to close, thus limiting access to abortion services for large numbers of mostly poor women. It is further alleged that these laws are nothing more than an end run around constitutionally guaranteed rights and are motivated by a desire to outlaw all abortion.

I am purposely leaving aside the above arguments for now. They are both valid and firmly held convictions on the part of those who wish to maximize the availability of abortion services. I do not necessarily agree with the motivations of the lawmakers who have passed these laws, nor do I personally believe that there should be no regulation of abortion under any circumstances.

What I have attempted to do is to assess the risk of first and second trimester abortion in the outpatient setting, compare that risk to other commonly done outpatient procedures and then compare the state and local regulations that are available for review covering various types of outpatient facilities.

Unfortunately, there is surprisingly little hard data on the risks associated with outpatient abortion. Organizations such as Planned Parenthood and the American College of Obstetrics and Gynecology have issued position papers estimating the risk of ‘significant complications’ at around 0.7/1000 abortions. A review of their citations for deriving that number done through Google Scholar and Medline searches turns up only a handful of studies, most over twenty years old, to support that number. The best and most highly powered (meaning a large number of patients studied over a sufficient period of time) is from 1998 and was done through a retrospective review of 97,000 first trimester abortions over a fifteen year period. Their findings are clearly the numbers that are commonly cited: a 0.71/1000 incidence of complications requiring hospital admission. But there was also an 8.46/1000 incidence of complications requiring some sort of emergency room or urgent clinic visit. Several much smaller studies have shown similar risks, although one from Scotland cited numbers as high as 2.8/1000 hospitalizations.

Bottom line: depending on whether you are an optimist or a pessimist, outpatient first trimester abortion is a reasonably safe procedure with a low risk of major complications, but that risk is not zero. Pessimistically, a prudent provider should have contingency plans for dealing with the small number of patients who have a problem requiring hospitalization. Fair statements?

How does this compare with other outpatient procedures? For comparison, I chose outpatient colonoscopy because it is a common procedure often done in freestanding dedicated endoscopy centers, requires at least some moderate sedation to accomplish, and has potential complications that may require admission to a hospital. I also tried to look at the increasingly common office GYN practice of doing hysteroscopy and ablation as an office procedure with local or sedation anesthesia.

Colonoscopy has been much better studied. The most recent large-scale study was from New Zealand and looked at 15,000 outpatient colonoscopies over a five-year period. The urgent hospital admission rate for colonoscopy related problems (excluding cardiac or respiratory issues) was 0.85/1000 procedures. This incidence compares well with the risks cited for abortion.

Office GYN data was harder to obtain, involves smaller numbers, and was not randomized. Overall, there appears to be a 36.4/1000 incidence of ‘reported complications’. But that number includes everything from low-grade fevers to phlebitis to uterine perforation, so it is difficult to compare it to the data for abortion. Nevertheless, state and local health regulations and professional society recommendations are available for this situation.

Most professional societies recommend that the provider doing these procedures either have admitting privileges at a hospital in the area, or have a standing admission arrangement to care for patients who have complications.

State regulations covering outpatient surgical and endoscopy facilities require a written plan to deal with emergency complications that occur on site. These vary but almost always include a designated hospital to which patients will be transferred and many require written agreements for admission should that become necessary. Note, though, these are regulations or recommendations, not statutes, so they are subject to reinterpretation and revision by the regulating agency without involvement of the legislature.

The statutes, which have been proposed or passed regarding abortion clinics, reflect many of these recommendations but escalate those recommendations to the level of statutory law. This singles out these clinics for special consideration and to that extent, the critics of these laws are correct. On the other hand, in many states, these clinics are exempt from the regulations governing outpatient surgery or endoscopy facilities. That is a different kind of special treatment that may be just as invalid. These clinics generally do only one or two types of procedures, often under local anesthetic only. But the incidence of complications with this technique is not zero and is comparable to endoscopy. Endoscopic facilities, at least in AZ and surrounding states, must meet more stringent regulations than facilities that provide abortion services.

In summary, the laws requiring admission privileges are not overly outrageous in concept, but do constitute a special escalation of statutory requirement aimed at abortion centers alone. For this reason they are not valid unless they include ALL centers that perform any type of invasive procedure.

Personal position: ALL facilities that do invasive outpatient procedures should be governed by the same set of regulations and requirements. No increased requirements unless there is documented increased risk that needs to be addressed. No laxity of requirements for procedures that are covered under the umbrella of ‘reproductive rights’. At a minimum, abortions clinics should have written policies and procedure for dealing with complications at the facility and should have transfer arrangements made in advance for patients who require hospitalization. Outpatient surgery and endoscopy centers have these provisions. Abortion clinics should too.

Philosophical statement: As a surgeon, I find it irresponsible at best for a provider to do a procedure with a low but inherent risk of a major complication and not have the ability to take care of that patient in the event that the complication occurs. I am not proposing that this position be made law, but I am tired of cleaning up other people’s messes. Here I am not referring to abortion, but to the plastic and cosmetic surgeons who do outpatient operations and have no admitting privileges to take care of their breast augmentation or tummy tuck patients who bleed or get infected after release form their private surgicenters. I extrapolate this to providers who do D&C, vacuum curettage, or other invasive abortions and who cannot admit the very few patients who have a problem. The fact that something is rare is not an excuse.

Anyone who has spent time on the Internet has seen those annoying pop-up ads that contaminate commercial websites. Now, thanks to the Electronic Medical Record, physicians can enjoy the same type of interference as they are trying to negotiate patient charts.

One of the features of most EMR systems are pop-up alerts that trigger for any number of reasons and interrupt the flow of charting to inform you of some problem or demand some action. Some of these are useful, such as a pop-up warning that the patient is allergic to the antibiotic that you just tried to order. Others are merely annoying, such as the Medicare two midnight certification you have to attest to before you can make your over-65 patient an inpatient admission. But the net effect of all of these pop-ups is alert fatigue. They happen so often, and are so often for trivial reasons, that you tend to ignore them and click the boxes until the alert goes away and you can get on with your work.

I recently had six Priority Alerts (oh my!) trigger on one patient in the course of a routine 23hr postoperative observation period following an uncomplicated hernia repair. The patient was doing fine and none of the ‘Priority Alerts’ was valid, or in my opinion a priority. Two were completely off base and had I just ‘clicked boxes’ would have resulted in unnecessary imaging and testing with some potential morbidity.

How did we get here? I wish I knew. I tried to research some of the alerts through my department committee and went down a rabbit hole of diffused responsibility, well-intentioned effort and contradictory responsibility. These alerts can be placed in the system by just about anyone. The hospital administration places them to try to comply with CMS admission guidelines. Various departmental committees place them to improve compliance with best practice guidelines. The pharmacy is sometimes the worst offender, placing not only allergy alerts but drug interaction alerts that range from important, such as warning that two drugs have potentially fatal interactions, to the stupid, such as warning me that hypertonic solutions may cause phlebitis. Each of these may seem like a good idea, but they are given equal weight in the EMR (IT people and the computer can’t tell if something is important or trivial) so that the fatal interaction alert looks the same as the warning that ibuprofen should be given with food.

I asked some of my hospitalist friends what they do to handle these alerts and most of them have gotten to the point where they ignore them. So if most doctors are ignoring the alerts, what good are they?

There are a few good studies of specific types of alerts such as severe drug interaction warnings or allergy warnings that seem like a good idea but failed to show significant improvement in the incidence of these types of errors. Why? I suspect because we were already pretty good at looking for this type of stuff with multiple layers of check by the physician, the pharmacy and the nursing staff.

Other alerts, such as the sepsis alert that triggers for certain combinations of abnormal vital signs, seem to show better results at the institutions where they were tested, but no one has looked at the numbers of patients for whom the interventions triggered were not necessary. And a careful look at the data shows that many of these institutions had poorer than average results BEFORE the alert was instituted. It isn’t as hard to make a poor outcome look better as it is to make a good outcome look stellar.

The only solution I can see is to create yet another layer of bureaucracy to oversee the inclusion of automatic alerts into the record. That sort of solution grates on me, though. We have too many committees and advisory groups telling us how to practice medicine as it is. Creating some physician oversight of these alerts would return some measure of control to the practicing doctor, but only at the cost of more time spent in a meeting room and less time at the bedside.